Placebo schmebo – fostering ‘caring effects’

Tasty little sugar pills

The BMA, James Le Fanu and Martin Robbins are all discussing homeopathy and the issue of placebo has raised its head.

I agree with Margaret McCartney’s comment on this – the debate needs to move on to the recognition that ‘caring effects’ are what we need and they shouldn’t be confused with the little sugar pill itself. She states:

The missing link is what placebo actually means: caring effects. We can get good caring effects when we spend time listening, when we follow people up carefully and consistently, when we take longer appointments, when we explain properly and usefully what the problems are and what might help. There is evidence for this: we know that using such ‘caring effects’ makes people better, faster, and for longer.

People talk about placebo effect but we need to start separating out these ‘caring effects’. They are not properties of the sugar tablet – they are real and tangible actions taken by the doctor or properties of the system within which the person gets their care.

Some evidence on placebo

Bandolier’s Little Book of Making Sense of the Medical Evidence looked at some of the trials that suggest placebo effect. They showed placebo effect ranging from 18-88%. But when aggregated (12,000 patients) the proportion of patients achieving 50% pain relief with placebo in post-op pain was 18%. They say:

Statements suggesting that one-third of people respond to placebo or that people respond to the placebo at one-third of the maximum response are wrong. The information above shows that both are wrong. It takes a long time to debunk widely held beliefs.

Exactly the same criticism that is so often levelled at shoddy CAM trials has been used, unchallenged by skeptics, to build up the placebo myth. The fact is that the large placebo responses in some smaller trials can be explained by chance alone.

This makes much more sense and I think we need to be a darn sight more discerning about placebos. The problem with over-egging placebo is that it’s one of the issues at the heart of the problem when persuading people that some of the more outlandish alternative therapies are ludicrous. Many people are prepared to accept CAM because of the widely perceived wonderfulness of placebo.

Ben Goldacre’s Radio 4 programme on placebo (part 2 available here) stated that it is:

One of the most effective and neglected evidence based treatments known to man.

Cochrane is fairly well accepted to know their way around the evidence. What do they say about this ‘neglected’ option?

Placebo interventions for all clinical conditions (Review)

It has been widely believed that placebo (dummy) treatments (for example sugar tablets) are associated with substantial effects on a wide range of health problems. However, this belief is not based on evidence from randomised trials that use a placebo treatment for one group of people, while another group receives no treatment. The effect of placebo treatments was studied by reviewing more than 150 such trials covering many types of health care problems. Placebo treatments caused no major health benefits, although they possibly had a small effect on outcomes reported by patients, for example pain.

They also added:

There was no evidence that placebo interventions in general have clinically important effects. A possible small effect on continuous patient-reported outcomes, especially pain, could not be clearly distinguished from bias.

I am not convinced that we are neglecting a major therapeutic option.

The ‘caring effects’

I would argue that doctors that have a positive attitude do not ‘amplify’ the placebo effect. It is quite simply an obvious and rational intervention and not some latent property of the pill. It’s one of Margaret McCartney’s ‘caring effects’ and we need to recognise them in order to foster them within the healthcare system.

Placebo seems to have an almost mythic status as a health intervention. The danger is that it is interpreted as some kind of magical effect; one that is beyond science and rational thought.

We can quite possibly learn a lot about we how deliver care to maximise ‘caring effects’ by studying placebo. However, we need to temper this with a dose of reality – it is really the little sugar pill having the effect?